A nurse is planning to administer a tuberculin skin test to a client who has had an exposure to tuberculosis. Which of the following actions should the nurse plan to take?

Inject 0.3 to 0.5 mL of the solution.

Select an injection site that is free of scar tissue.

Hold the needle at a 30° angle during injection.

Massage the site following the injection.

Answer and Explanation

The Correct Answer is B

A. Inject 0.3 to 0.5 mL of the solution: The typical volume for a tuberculin skin test is 0.1 mL.
B. Select an injection site that is free of scar tissue: Scar tissue can interfere with the reading of the tuberculin skin test, so a site free of scars should be selected.
C. Hold the needle at a 30° angle during injection: The needle should be held at a 5–15° angle for intradermal injections.
D. Massage the site following the injection: Massaging the site is not recommended as it could affect the accuracy of the test.

Nursing Test Bank

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Correct Answer is ["D","G","H"]

Explanation

Client reports having three to four alcoholic beverages a couple times per week: Alcohol can interact with phenytoin, either enhancing its effects or reducing its efficacy. Chronic alcohol use can induce liver enzymes, altering phenytoin metabolism and potentially leading to subtherapeutic or toxic levels.

Client takes diazepam as needed for anxiety: Diazepam and phenytoin can interact, increasing the sedative effects and potentially leading to central nervous system depression. Monitoring is essential when these drugs are coadministered.

Last menstrual period was 3 months ago: This finding may indicate a possible pregnancy, which is critical because phenytoin is teratogenic and classified as a Pregnancy Category D drug. Immediate follow-up is required to rule out pregnancy before starting phenytoin therapy.

Temperature 35.4°C (97.6°F), oral: This is slightly lower than the normal range and does not require immediate follow-up.

Blood pressure 100/74 mmHg: This is within the expected range and does not contraindicate phenytoin use.

Client is a vegetarian and takes a multivitamin daily: A vegetarian diet is not a contraindication, though it may necessitate monitoring for folic acid levels since phenytoin can deplete folate.

Client has varicose veins: Varicose veins do not affect phenytoin use or metabolism.

Last bowel movement was 3 days ago: While mild constipation should be noted, it does not contraindicate phenytoin use.

A. "Your child will receive another MMR immunization and the hepatitis B immunization at 3 years of age." B. "Your child will receive two more MMR immunizations over the next 2 years." C. "Your child will receive another MMR immunization at 4 to 6 years of age." D. "Your child will have an MMR titer taken to determine the need for further immunizations."

Correct Answer is C

Explanation

A. "Your child will receive another MMR immunization and the hepatitis B immunization at 3 years of age.": The next MMR immunization is typically at 4-6 years, not 3 years.
B. "Your child will receive two more MMR immunizations over the next 2 years.": Only one more MMR vaccine is given at 4-6 years of age.
C. "Your child will receive another MMR immunization at 4 to 6 years of age.": The second dose of MMR is given between 4-6 years of age.
D. "Your child will have an MMR titer taken to determine the need for further immunizations.": Routine titers are not required for MMR unless there is a specific concern.

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Body System	Findings
Vital Signs/General History	Temperature 35.4 °C (97.6 °F), oral Heart rate 75/min Respiratory rate 16/min Blood pressure 100/74 mmHg Oxygen saturation 99% on room air Client is a vegetarian and takes a multivitamin daily Client reports having three to four alcoholic beverages a couple times per week.
Integumentary	Skin color is consistent with genetic background. No rashes or lesions. The client has varicose veins.
Cardiovascular/Respiratory	S1S2 auscultated. No murmurs. All peripheral pulses 2+. Lung sounds clear bilaterally.
Gastrointestinal/Genitourinary	Abdomen soft, nontender. Normoactive bowel sounds in all 4 quadrants. Last bowel movement was 3 days ago. Voids four to five times a day. Urine is clear, yellow, and odorless. Last menstrual period was 3 months ago.
Neurologic/Musculoskeletal	Alert and oriented to person, place, and time. Client takes diazepam as needed for anxiety. Client has full range of motion and is able to maintain flexion against resistance in all four extremities.

Prescribed Medication	Nursing Instruction
Albuterol	"Take your albuterol when you are having difficulty breathing.” "Hold your breath for 20 seconds when taking your albuterol.”
Salmeterol	"Take the salmeterol 5 minutes before the albuterol when you need both medications." "Take the salmeterol 2 times each day."
Fluticasone	"Rinse out your mouth after taking the fluticasone." "Take the fluticasone as needed for an asthma attack."

A nurse is planning to administer a tuberculin skin test to a client who has had an exposure to tuberculosis. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["D","G","H"]

Explanation

A nurse is reinforcing teaching with the parents of a 13-month-old child following administration of the measles mumps rubella (MMR) Immunization. Which of the following statements by the nurse is appropriate?

Correct Answer is C

Explanation

A nurse is evaluating the laboratory results of four clients. The nurse should report which of the following laboratory results to the provider?

A nurse is caring for a client who had abdominal surgery. The client is grimacing and has a respiratory rate of 24/min. Which of the following actions should the nurse take first?

A nurse working in an urgent care clinic is collecting data from a client who takes montelukast. Which of the following is an expected therapeutic effect of this medication?

A nurse is preparing to administer regular and NPH insulin to a client. Which of the following actions should the nurse take?

A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who has a new prescription for sustained-release verapamil. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a client who states she recently started taking garlic as an herbal supplement. The nurse should advise the client to stop taking garlic due to a potential reaction with which of the following client medications?